Exposure and Response Prevention Therapy
Obsessive-compulsive disorder, or OCD, is a mental illness that affects about 1 percent of the American adult population within a given year, the National Institute of Mental Health (NIMH) publishes. Characterized by obsessions, or anxiety-producing thoughts, followed with compulsions, or behaviors that are repeated to reduce the anxiety, about half of the people in the US who struggle with OCD have a severe form of the disorder that drastically disrupts daily life functioning. Individuals may spend hours every day on rituals to try and dispel anxiety.
Exposure and response prevention therapy, or ERP, is a form of Cognitive Behavioral Therapy (CBT) that is considered to be the most effective form of treatment for adults and children who suffer from OCD, as reported by the journal Case Reports in Psychiatry. It should be performed by a professional therapist in structured sessions, at least initially. With time, individuals may be able to practice ERP on their own at home. The goal of exposure and response prevention therapy is to help individuals suffering from OCD learn how to face their fears through safe exposure and then how to stop performing disruptive ritualistic and obsessive behaviors.
Basics of Exposure and Response Prevention Therapy
The American Psychological Association (APA) publishes that exposure and response prevention therapy sessions are generally about two hours; they take place 2-5 times a week for a total of 17 sessions. Homework is given in between sessions.
Individuals battling OCD often suffer from more than one obsession and various repetitive behaviors. They may feel the need to constantly wash their hands for fear of germs, feel the need for symmetry and repeatedly organize things, or have thoughts of harm and constantly need to check that doors and windows are locked.
Exposure and response prevention therapy exposes individuals to their anxiety-producing thoughts while teaching them how to not respond with the ritualistic behaviors. The exposure component of ERP helps people to confront their fears by exposing them to situations that cause anxiety. This may not be particularly concerning at first since someone suffering from OCD will then use their obsessive compulsion to avoid feeling anxious. The response prevention piece of ERP keeps a person from engaging in their ritualistic behaviors as a coping mechanism. The goal is to lessen the anxiety felt through exposure and then prevent the initiation of compulsions in order to realize that the fears are unfounded and unrealistic.
Typically, the first two sessions are spent in the information gathering phase of exposure and response prevention therapy, so the clinician can better understand what the fears, obsessions, and compulsions are, and get a handle on the specific nuances of the OCD and associated behaviors. The avoidance patterns and triggers need to be specifically uncovered and identified. After the first session, homework is usually given that includes a personal assessment in order to self-monitor triggers and responding behaviors.
In the third session, the therapist will usually introduce the first exposure experience. Exposure exercises may be “in vivo,” or direct exposure, or “imaginal” which is virtual exposure to fears that cannot be directly confronted, such as the fear of killing family members or fear of getting into an accident while driving. The exposure exercises generally address issues that produce a low to moderate amount of anxiety first, building up to more anxiety-producing situations with subsequent sessions. In general, all anxiety-provoking thoughts and situations are addressed by the sixth session. Then, all remaining sessions can introduce new variations and help to build on what has been learned.
Individuals are encouraged to stay in the anxiety-ridden situations they are being exposed to for as long as possible without doing anything. With time, the anxiety will reduce on its own. The next time a person is exposed to the same trigger, the anxiety should be less than the time before. This is called habituation, and the person gets used to a certain level of anxiety.
It is important that the individual not engage in any avoidance or distraction techniques during exposure therapy. The point is to lessen the fear by exposure instead of engaging in ritualistic behaviors. The ritual prevention component of ERP can be difficult at first. If it were easy to stop engaging in obsessive-compulsive behaviors, people would be able to stop doing so on their own. This is why ERP builds up in a kind of hierarchy from low-level anxiety-producing triggers to higher ones over time, in each instance preventing the individual from performing their habitual and obsessive ritual.
The obsessive thoughts and actions actually serve to make the anxiety worse, even though they seem to lessen it at the time. In fact, they are merely an avoidance tactic that perpetuate OCD. Through exposure and response prevention therapy, individuals can learn that the anxiety will get better without engaging in the ritualistic behaviors or giving in to the obsessive thoughts. ERP allows individuals to confront their fears head on and assess the actual risks realistically instead of through avoidance. As Psychology Today publishes, this practice can make a person stronger and more able to deal with daily life.
Pros and Cons to ERP
The journal Trials publishes that exposure and response prevention therapy works only about half the time. One of the reasons for the high rates of failure is that people do not complete their sessions and drop out of a treatment program before it is completed. Others simply do not continue to engage in the homework or ritual prevention techniques outside of the sessions. As ERP progresses, individuals are expected to spend several hours actively practicing what they have learned in order to keep moving forward. ERP can fail if an individual does not put in the work.
Critics of exposure and response prevention therapy claim that the exposure is too dangerous and scary. At times, a therapist may ask clients to engage in activities or put themselves into situations that may carry some element of risk. Some critics say it is cruel to expose individuals to what they fear most in the world.
The benefits are thought to outweigh the risks, however, as exposure and response prevention therapy is one of the main therapy forms used to treat OCD.
ERP may be used as part of a treatment plan that includes other forms of therapy and medications, Mayo Clinic reports. One of the main benefits of ERP is that individuals can practice the methods anywhere and anytime that triggers may arise in order to quell anxiety and avoid engaging in obsessive and compulsive behaviors.
With time and repetition, cognitive-behavioral therapies can actually help to rewire the brain in a more positive manner, building a new pathway to reward and calming down a hyperactive nervous system response. Studies published in the journal the Psychiatric Times have shown how CBT can actually improve brain structure and function over time, enhancing positive connections and brain circuitry. As a form of CBT, ERP may then have a similar positive effect.
Exposure and response prevention therapy helps a person gain insight into their obsessions and to realize that their fears are unrealistic. OCD can be managed with the help of a trained professional who uses exposure and response prevention therapy in order to provide the person with the necessary tools to control the disorder on their own in the future.
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